RHODE ISLAND DEPARTMENT OF HUMAN SERVICES APPLICATION FOR ASSISTANCE (DHS-2)

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1 RHODE ISLAND DEPARTMENT OF HUMAN SERVICES APPLICATION FOR ASSISTANCE (DHS-2) Instructions Page 1 of 4 General Instructions for Completing this Application You can ask for help in completing this form. You can ask for the form and notices to be translated. If you have a disability or condition that makes it hard for you to understand or answer questions on this application, we can help. Please let us know by speaking with a DHS representative or calling the DHS Information Line at If you would like to apply for Medicaid affordable health care coverage, you must complete a different application. Health care coverage is available for families with income up to 133% of the Federal Poverty Level (FPL), children and pregnant women with income up to 250% of the FPL and childless adults age 19 to 64 with income up to 133% FPL. Adults with disabilities who do not need long term services and supports or adults who do not meet criteria for a disability determination or have too much money in the bank may apply for affordable health care coverage. You can apply for health care coverage in the following ways: online at calling the HRSI Contact Center at in-person, at a local DHS Office mailing in a paper application. Applications can be found online at under What's New?" or "Forms and Applications Answer All Questions If you answer all the questions on the assistance application, we can determine if you are eligible for ALL programs. The program symbols below will appear next to each of the questions on the application. These symbols tell you which questions you must answer for each program. If the symbol for the program(s) you are applying for appears next to the question, you must answer that question. RI Works (RIW) Cash Assistance: The RIW Program gives cash assistance for a limited number of months to families in need of support, as well as those who are unable to work, or in training or looking for a job. Applicants for RIW must be responsible for the support and care of a child under age 18, or between 18 and 19 if enrolled full-time in and expected to complete secondary school prior to their 19th birthday. RIW cash assistance requires an interview with an eligibility worker and a meeting with a Social Caseworker to complete an employment plan. Supplemental Nutrition Assistance Program (SNAP): The SNAP program helps low income households buy the food needed to stay healthy. You may be able to get SNAP benefits within 7 days if your household has little or no income, your rent or housing costs are higher than your income/resources, or if you are a seasonal or migrant farmworker. All other households will receive an eligibility determination within 30 days of the application filing date. You will need to participate in an interview over the telephone or in the office before you can be granted SNAP benefits. Medicaid: Long Term Services and Supports: Medicaid Long Services and Supports (LTSS) are available for individuals age 65 and older and for individuals with disabilities. You must meet both the financial and functional/clinical level of care need to qualify for eligible LTSS. The types of services available include Nursing Home Care or Home and Community Based Services. Services include but are not limited to homemaker/cna services, Environmental modifications, Case Management, Assisted Living, Personal care services (self-directed care), respite, minor home modifications and shared living/rite at Home. The type of services you receive depends on your level of care needs. Medicaid/Health Coverage for Aged, Blind and Disabled (ABD) and Working Adults with Disabilities/Sherlock Plan: To qualify for Medicaid under the ABD category, an individual or member of a couple must be age 65 years or older, blind or disabled. Your income, resources and health needs will determine if you are eligible. Individuals who receive Retirement, Survivors and Disability Insurance (RSDI) or Supplemental Security Income (SSI) based on disability meet the criteria for disability. For all others, a disability review must be completed and determination of disability must be made before eligibility for Medicaid based on disability can be established. Medicaid for Working People with Disabilities Program/Sherlock Plan: People eligible under this category are entitled to the full scope of Medicaid benefits, home and community-based services, and services needed to facilitate and/or maintain employment. To be found eligible for this program, a person must be at least eighteen (18) years of age, meet the Medicaid requirements for eligibility based on a disability, have proof of active, paid employment and meet the income and resources standards. General Public Assistance (GPA) Program: GPA is available for adults age years of age who have very limited income and resources and have an illness or medical condition that keeps them from working. Sometimes, adults who have a current pending application for Supplemental Security Income (SSI) may be determined eligible for GPA benefits. A determination for Medicaid affordable care coverage must be completed prior to a determination of eligibility under a disability. GPA applicants can apply for affordable healthcare coverage by completing the UHIP LF-1, Application for Health Care Coverage or by applying online at Child Care Assistance Program (CCAP): Child Care Assistance is only available to families with earnings up to 180% of the federal poverty level for your family size and only available to cover hours of employment or short-term training. Families may be required to pay a co-payment based on their family size, income level, and number of children. For parents that participate in the Rhode Island Works Program, there is no income limit for child care because if a family is eligible for RI Works, they already meet the income requirements for the Child Care Assistance Program (CCAP). Prior to enrollment, RI Works applicants or participants who are not employed must discuss child care options with a Social Worker as part of the assessment process and the development of the employment plan. For families not participating in the RI Works Program, eligibility for child care assistance is based on working at least 20 hours per week at or above Rhode Island's minimum wage.

2 Instructions Page 2 of 4 Medicare Premium Payment Program (MPP): Eligibility for the Medicare Premium Payment Program (MPP) is based on income and helps adults over age 65 and disabled adults pay all or some of the costs of Medicare Part A and Part B premiums, deductibles and co-payments. Medicare Part A is hospital insurance coverage and Medicare Part B is for physician services, durable medical equipment and outpatient services. RI SSI State Supplemental Payment Program (SSP): The State of Rhode Island supplements the Federal SSI benefit rate for eligible persons. Supplemental Security Income (SSI) is a federal program that provides monthly benefits to people who are age 65 or older, blind or disabled and who have low income and limited resources. Authorization of the monthly SSP for current SSI recipients will be completed automatically. New applicants who are eligible for the Federal SSI will be automatically authorized for the SSP when they apply at the SSA. Applicants for SSP who have been denied through SSA for excess income will need to meet the income, resource, age and/or disability standards (age 65 or older, disabled or blind). If an applicant is eligible based on income and is claiming a disability which has not been reviewed or determined by the SSA, the SSP Unit will send a referral to the Medical Assistance Review Team (MART) for a disability determination. Katie Beckett: Katie Beckett provides Medicaid/health insurance coverage to children under age 19 who have long-term disabilities or complex medical needs. Katie Beckett enables children to be cared for at home instead of in an institution. With Katie Beckett, only the child s income and resources, not the parents, are used to determine eligibility. If you are applying for Katie Beckett, you only need to provide information for the applicant child you do not need to fill in information about other household members. This form consists of 38 questions. Except for Question 1, each is followed by a section of boxes used for filling in the required information. Respond to each question by indicating either YES or NO with a check mark in the box next to the question. IF the answer is YES Supply the requested information by writing in the space available or in the yellow-boxed area beneath the question. Do not write in the blue shaded areas. You must provide the information asked for EVERY household member whether or not you are requesting assistance for her or him. IF the answer is NO THE QUESTION DOES NOT APPLY TO YOU OR ANYONE IN YOUR HOUSEHOLD. With the exception of Question 38, leave the yellow box blank, and move on to the next question. IF you need more space to answer questions "SEE PAGE 26" if you run out of space. Turn to page 26, where there are boxes to write in additional information. Indicate in one of the boxes, which question you are referring with its number. You may also attach separate sheets of paper, if necessary. Read pages These pages contain important information about your Rights and Responsibilities. About the Interview Page 3 of the instructions has a list of "Things You May Need to Provide for Your Interview or Submit for Benefit Approval". About the Questions Question 1. List yourself on the first line providing all the requested information. Then list all persons who live with you, one person per line. Indicate how each person is related to you (for example "son", "cousin", etc.) in the "Relationship" block. You must list each person who lives in your home REGARDLESS OF WHETHER OR NOT YOU ARE SEEKING ASSISTANCE FOR THAT PERSON. Question 1a. through 13. Complete the information in the yellow areas for each person requesting assistance. These questions follow the list of household members (Question 1.) and ask for personal information about everyone listed in Question 1. If the answer to any of these questions is YES complete the information asked for in the yellow shaded area. When doing so, write the names of household members exactly as they appear in Question 1. Question 14. through 19. These questions ask about the financial assets (such as bank accounts) of all household members. If the answer to any of these questions is YES, complete the information asked for in the yellow shaded area. When doing so, write the name of household members exactly as they appear in Question 1. Questions 20. through 28. These questions ask about the income of all household members. If the answer to any of these questions is YES, complete the information asked for in the yellow shaded area. When doing so, write the names of household members exactly as they appear in Question 1. Questions 29. through 38. These questions ask about shelter and miscellaneous expenses and medical coverage of all household members. If the answer to any of these questions is YES, complete the information asked for in the yellow shaded area. When doing so, write the name of household members exactly as they appear in Question 1. If you report and provide proof of your expenses as listed in questions 29-38, it may help you get more benefits from SNAP. If you do not report an expense or provide proof, then we will assume that you do not want this expense to be counted. You can ask for assistance in getting documentation of the deductions and/or expenses from your DHS worker. Appointing an Authorized Representative: If you would like to appoint an authorized representative to act on behalf of the household in applying for program benefits or using the benefits you may do so on pages 1 and/or 29.

3 Instructions Page 3 of 4 This document should be filled out by you or an adult member of your household, or a relative, friend or authorized representative who knows the financial situation of all household members. On the following pages list all members of your household. If you answer Yes to a question, your answers must be complete, clear and correct before your application will be processed. If they are not, additional information may be requested. If you do not understand a question, please call for assistance. If you need more space to report information, use page 26 titled, For Client Use Only. ELECTRONIC BENEFIT TRANSER (EBT) CARD RIW cash assistance and SNAP benefits are issued through the Electronic Benefit Transfer (EBT) process. You can get your benefits by using your EBT card. You will receive more information about this process from your local office. DOCUMENTS YOU MAY NEED TO PROVIDE FOR YOUR INTERVIEW OR SUBMIT FOR BENEFIT APPROVAL Award letters or proof of Social Security, SSI, UCB, TDI, Worker s Compensation, etc. Bank statements for checking accounts, savings accounts, certificates of deposit, credit union accounts, or stocks and bonds Birth Certificate for all household members Child care receipts Copy of child support orders, proof of child support and/or alimony payments, divorce decree, marriage license Death certificate of deceased parent for any dependent child for whom you may be applying or for any deceased Medicaid applicant Deeds for any home or property Proof of identity (driver s license, rent receipt, etc.) If not a U.S. Citizen, proof of Immigration status Proof of income from rental property Proof of medical expenses such as: medications, hospital bills, doctor bills, or insurance premiums Proof of health and or dental insurance coverage and premium amount paid Life insurance policies and Burial contracts Passport or Certificate of Naturalization or other documentation to prove Citizenship and Identity Pay stubs, pay envelopes, earnings statement and/or proof of last date worked and last pay Pensions and any other unearned income Proof of pregnancy, if pregnant Copy of Power of Attorney or guardianship Public Assistance/MA/SNAP closing notice from another state Rent receipt/mortgage payment (including home insurance, taxes, and other shelter expenses) Self-employed persons: Federal tax return, bookkeeping records, or sales and expenditures records Social Security numbers for all household members and absent parents Trust documents, complete annuity contract and promissory notes Utility receipts Vehicle registration (s) Veteran s claim number SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) Your SNAP application will be considered from the date the signed form is received. If you are found eligible for SNAP benefits, those benefits will be determined from the date your signed application is received by the agency. You will be sent a written request for any verification missing from your application. Your application will be denied if the missing verification is not received within ten (10) days of the written request. FINANCIAL ASSISTANCE (RIW) (GPA) (CCAP)(SSP) If you are applying for RIW GPA, CCAP or SSP and are determined eligible for benefits, those benefits will be determined from the date the signed application is received. MEDICAID Medical benefits for adults may be provided for up to three (3) months prior to the month in which the signed application is received provided all factors of eligibility are met for each month. DO NOT WRITE IN BLUE SHADED AREAS WRITE IN YELLOW SHADED AREAS ONLY

4 Your DHS Office Depends On Where You Live and Which Benefits You Have Requested: Instructions Page 4 of 4 Office Locations OFFICE ADDRESS TELEPHONE Cranston Adult Service/Long Term Services and Supports Office Serves: Adult/LTSS for Cranston, Charlestown, Coventry, East Greenwich, Exeter, Foster, Hopkinton, Johnston, Narragansett, New Shoreham, North Kingstown, Richmond, Scituate, South Kingstown, Warwick, West Greenwich, West Warwick, Westerly Bldg. #55, Howard Avenue, Cranston, RI Office Referrals Child Care Assistance Program (Statewide) Providence Regional Family Center 206 Elmwood Avenue, Providence, RI DHS Information Line (Statewide) (TTY) Disability Determination Services (Statewide) East Providence Adult Service/Long Term Services and Supports Office Serves: Adult/LTSS for Barrington, Central Falls, East Providence, Pawtucket, Warren Katie Beckett Unit (Statewide) Newport Office/Long Term Services and Supports Office Serves: Jamestown, Little Compton, Middletown, Newport, Portsmouth, Tiverton, Warren Office of Rehabilitation Services Vocational Rehabilitation Services Office of Rehabilitation Services (ORS) 40 Fountain Street., Providence, RI (TTY) Providence Regional Family Center, 206 Elmwood Avenue, Providence, RI West Road, Hazard Bldg. Ground Level, Cranston, RI Newport Regional Family Center, 272 Valley Road Middletown, RI (Statewide) 40 Fountain Street, Providence, RI Pawtucket Office Serves: Barrington, Bristol, Central Falls, East Providence, Pawtucket, Warren Pawtucket Regional Family Center GPA: North Providence 249 Roosevelt Avenue, Pawtucket, RI Providence Office Providence A/LTSS Waiver Unit Providence Nursing Home LTSS Providence LTSS- Home and Community Based Services Serves: North Providence, Providence GPA: Foster, Johnston, Scituate, Providence Providence Regional Family Center, 206 Elmwood Avenue, Providence, RI Services for the Blind & Visually Impaired (Statewide) 40 Fountain Street, Providence, RI South County Family Center Serves: Charlestown, Coventry, East Greenwich, Exeter, Hopkinton, Narragansett, New Shoreham, South County Regional Family Center North Kingstown, Richmond, South Kingstown, Oliver Stedman Center West Greenwich, Westerly 4808 Tower Hill Road, Suite G1, Wakefield RI Veterans Home (Statewide) Warwick Office Serves: Warwick, West Warwick GPA: Charlestown, Coventry, Cranston, East Greenwich, Exeter, Hopkinton, Jamestown, Little Compton, Middletown, Narragansett, Newport, New Shoreham, North Kingstown, Portsmouth, Richmond, South Kingstown, Tiverton, Warwick, West Warwick, Westerly 480 Metacom Ave., Bristol, RI Warwick Regional Family Center 195 Buttonwoods Avenue, Warwick, RI Woonsocket Office/Long Term Services and Supports Office Serves: Burriville, Cumberland, Foster, Glocester, Lincoln, North Providence, North Smithfield, Smithfield, Woonsocket (GPA: all but Foster) 450 Clinton Street, Woonsocket, RI (Toll Free) (Spanish Line) (TTY) * (Toll Free) (LTSS) (LTSS) (SNAP) (TTY) (TTY) (Toll Free) (ext. 695) (TTY) (Toll Free) LTSS (TTY) (Toll Free)

5 RHODE ISLAND DEPARTMENT OF HUMAN SERVICES APPLICATION FOR ASSISTANCE Do you speak English? Yes No If No, what is the primary language spoken? Can you read and write in English? Yes No Do you need an Interpreter? Yes No If you do not speak English, does any adult member of the household speak English? Yes No I want to apply for: CASH ASSISTANCE (RHODE ISLAND WORKS PROGRAM- RIW) Page 1 SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) MEDICAID: LONG-TERM SERVICES AND SUPPORTS MEDICAID/HEALTH COVERAGEFORAGE 65 AND OVER, BLIND OR DISABLED ANORRKING ADULTS WITH DISABILITIES (SHERLOCK PLAN) GENERAL PUBLIC ASSISTANCE (GPA) CHILD CARE ASSISTANCE PROGRAM (CCAP) MEDICARE PREMIUM PAYMENT PROGRAM (MPP) RI SSI STATE SUPPLEMENTAL PAYMENT PROGRAM (SSP) KATIE BECKETT: MEDICAID/HEALTH COVERAGE FOR CHILDREN WITH SEVERE DISABILITIES First Name M.I. Last Name Maiden Name Social Security # - - Date of Birth / / MARITAL STATUS: Single Married Divorced Other GENDER: Male Female Residence Address Street/Route Apt./Floor City State Zip Mailing Address (if different) Street/Route Apt./Floor PO Box City/Town State Zip If you are applying for SNAP benefits, how would you like to be interviewed? Check one of the boxes: Telephone Interview (DHS will call you) (OR) In-Office Interview Telephone Number: Day Evening If you wish to authorize someone other than yourself to apply on your behalf, please indicate below: I want to apply on my behalf. (Name of Individual) (Daytime Phone #) (Evening Phone #) Is anyone who wants assistance pregnant? Yes No If Yes, Name of Person: Due Date: YOU MAY GET SNAP BENEFITS, IF ELIGIBLE, WITHIN 7 DAYS IF: your income, cash and money in the bank add up to less than your monthly housing expense; or your monthly income is less than 150 and your money in the bank and liquid resources are less than 100; or you are a migrant or seasonal farm worker. a. How much money do members of your household have in cash or money in the bank? b. What is the total amount of income from any source (including unearned income such as Child Support, SSI, TDI, Unemployment, or SSDI, etc.) you expect your household to receive this month? c. What is your current monthly rent/mortgage payment? Utilities? d. Is anyone in your household a migrant or seasonal farm worker? Yes No Applicant s Signature **You may tear off this sheet and submit JUST the front and backside of this page with Name Address and Signature to allow us to date stamp and initiate this application. To determine ongoing benefit eligibility, you must sign and complete the remainder of this application. Date

6 Page 2 HOUSEHOLD COMPOSITION If you are applying for SNAP, list everyone who lives in your home now, even if they do not want assistance. If you applying for any other program, only enter the information below for the applicant, his/her, spouse and any dependents. If you are applying for the Katie Beckett Program, enter the information below for the child only. Last Name First Name D.O.B. (mm/dd/yyyy) Relationship S.S.N. (Only required if member is applying for benefits. If you are applying for child care only, this is needed for the child(ren)) U.S. Citizen? Answer Yes or No (Only required if member is applying for benefits. If you are applying for child care only, this is needed for the I live in a (Check one): 01 Elderly/disabled housing 06 Own home/trailer 11 Homeless: lobby, street, car 02 Drug/alcohol rehab center 07 Rent home/apt/trailer 12 Residential care and assisted living 03 Disabled/blind group home 08 Living in another s home/apt 13 Long-Term Care Facility 04 Battered Women s shelter 09 No permanent address 99 Other (specify) 05 Shelter 10 Halfway house Did you move to Rhode Island within the last three (3) Yes No If Yes, Date: months? If Yes, what was your reason for moving here? (check one) Looking for Employment Close to Relatives To get Cash, SNAP/Food Stamps, and/or Medical Domestic Violence Other (please specify) Which State did you move from? Information for SNAP applicants: You may file your application immediately as long as we have your name, address and the signature of a responsible household member or your authorized representative on this application. If you are determined eligible, benefits will be calculated from the date we receive this form in our office. We are required to verify information you provide and take action on your application within thirty (30) days of the filing date unless you are entitled to expedited service. To determine whether or not you are eligible, you must be interviewed. The application filing date for prerelease applicants is the date of release from the institution. Under penalty of perjury, I attest that all of the information contained in this application is true. I understand that I am breaking the law if I give wrong information and can be punished under federal law, state law or both. Signature of Applicant or Recipient Date Signature of Authorized Representative Date Are you receiving assistance from another State? Yes No Signature of Spouse or other parent of child(ren) Date Signature of Guardian, Conservator or Holder of Power of Attorney Date WITHDRAWAL OF APPLICATION ***FOR AGENCY USE ONLY*** After participating in the screening interview, I do not wish to make an application for RIW, SNAP, Medicaid, GPA, CCAP, MPP, SSP or Katie Beckett at this time. I understand that I may apply again at any time. I understand that this application will be denied and a notice of denial will be sent to me. Please state your reason for withdrawing your application: Applicant s Signature Date Agency Representative s Name: Date Screened Intake/Interview Date Program(s): Case ID

7 Page 3 First Name Middle Initial Last Name 1a Have you or has any member of your household been convicted of: 1b a) a felony under federal or state law for possession, use or distribution of a controlled drug substance (felony drug conviction) after August 22, 1996? YES NO b) trading SNAP benefits for drugs after September 22, 1996? YES NO c) buying or selling SNAP benefits over 500 after September 22, 1996? YES NO d) fraudulently receiving duplicate SNAP benefits in any state after September 22, 1996? YES NO e) trading SNAP benefits for guns, ammunitions or explosives after September 22, 1996? YES NO Are you or any one in your household fleeing to avoid prosecution, custody, or confinement after conviction under the law of the place from which you are fleeing, for a crime or attempt to commit a crime that is a felony under the law of the place from which you are fleeing or which, in the case of New Jersey, is a high misdemeanor under the state of New Jersey or violating a condition of probation or parole imposed under a federal or state law? YES NO Have you or anyone in your household ever been found through an Administrative Hearing process of having made, or been convicted in a Federal or State court of having made, a fraudulent statement or representation with respect to your identity or place of residence in order to receive multiple Supplemental Nutrition Assistance Program benefits simultaneously? YES NO Have you or any member of your household been barred from participating in the SNAP/Food Stamp Program in another state? YES NO The Rhode Island Department of Human Services (DHS) uses an Interactive Voice Response (IVR) system to make appointment reminder calls to remind you of a scheduled phone or office interview appointment. The reminders are for SNAP and Rhode Island Works certification and recertification appointments. Two days before your scheduled appointment, the IVR will automatically contact the number you have written on this application, unless you chose to opt out. Check here if you would not like to receive information about next steps in the application process from an automated telephone system: 1c If you live in a household with a minor child(ren) (under eighteen), is there more than one adult parent or adult who shares parental control/rights over the child(ren)? YES NO If you live in such a household, please designate an adult parent or an adult who has parental control of the child(ren) as the head of the household here. Name 1d Have you previously applied for, or received any type of assistance payments, benefits or SNAP/Food Stamp benefits in R.I. or in another state? YES NO If Yes, under what name? Where? When? Type?

8 1 List everyone who lives in your home now. (If you are applying for SNAP, list everyone who lives in your home now, even if they do not want assistance. If you applying for any other program, enter the information below only for the applicant, his/her, spouse and any dependents. If you are applying for the Katie Beckett Program, enter the information below for the child only). HOUSEHOLD Assistance asked for Page 4 Middle Last Name First Initial Relation to you SNAP RIW MA LTSS MA ABD GPA CCAP MPP SSP Katie Beckett None Date of Birth 1 / / 2 / / 3 / / 4 / / 5 / / 6 / / 7 / / 8 / / 9 / / If there are more people in your household, please list them on page 26 marked, for client use only.

9 MEMBERS Social Security # (Provide this information only if the person is requesting benefits. If you are applying for child care only, this is needed for the child(ren)) / / / / / / / / / / / / / / / / / / Gender F M F M F M F M F M F M F M F M F M *Race and Ethnicity We ask you to provide this information so we can make sure that all people are able to get the benefits they are entitled to and we are not discriminating against anyone. You do not have to provide this information. If you choose not to provide this information, it will not affect your eligibility for benefits. You may select more than one category under race. Marital Status (check one) Single Married Divorced/Separated Widowed Single Married Divorced/Separated Widowed Single Married Divorced/Separated Widowed Single Married Divorced/Separated Widowed Single Married Divorced/Separated Widowed Single Married Divorced/Separated Widowed Single Married Divorced/Separated Widowed Single Married Divorced/Separated Widowed Single Married Divorced/Separated Widowed U.S. Citizen? (Provide this information only if the person is requesting benefits If you are applying for child care only, this is needed for the child(ren)) Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Is this person Latino/ Hispanic? * Hispanic Not Hispanic Hispanic Not Hispanic Hispanic Not Hispanic Hispanic Not Hispanic Hispanic Not Hispanic Hispanic Not Hispanic Hispanic Not Hispanic Hispanic Not Hispanic Hispanic Not Hispanic If there are more people in your household, please list them on page 26 marked, for client use only. Page 5 Race* (You may select more than one race) American African White

10 Page 6 2 Are you, your spouse, or anyone in the household a military veteran, a dependent of a veteran, or a survivor of a veteran? Yes No If yes, complete the boxes below about each person. Middle Last Name First Name Initial Veteran s Status 3 Applied for Veteran s Benefits Date of Service Veteran Yes Dependent / / Survivor Veteran Yes Dependent / / Survivor Veteran Yes Dependent / / Survivor Were you, your spouse, or anyone in the household born outside the U.S? (If you are applying for Child Care or Katie Beckett, answer this question for the applicant child only.) Serial Number V.A. Claim Number Yes No **The alien status of applicant household members is subject to verification by USCIS (formerly known as INS) through the submission of information from this application to USCIS. Submitted information received from USCIS may affect your household s eligibility and level of benefits. If yes, complete the boxes below about each person that is requesting benefits who is not a U.S. citizen. ALIE Last Name First Name Middle Initial Country of Origin Alien Registration Number Immigration Number Alien Status: Refugee/Granted Aylum Date of Entry Permanent Resident Date of Entry Other Date of Entry Name of Sponsor USCIS Status Date Permanent Residence Date USCIS Status Date Sponsor s Address Did this individual reside in the US prior to 8/22/96? Yes Last Name First Name Middle Initial Alien Status: Refugee/Granted Aylum Date of Entry Permanent Resident Date of Entry Other Date of Entry Country of Origin Alien Registration Number USCIS Status Date Permanent Residence Date USCIS Status Date Immigration Number Name of Sponsor Sponsor s Address Did this individual reside in the US prior to 8/22/96? Yes

11 Page 7 Are you, your spouse, or anyone in the household in 4 a group living arrangement such as the types listed below? EXAMPLES Shelter for Homeless Drug Treatment Center Hospital Group Home Alcohol Treatment Center Shelter for Battered Women If yes, complete the boxes below about each person. Yes No Assisted Living Facility Dormitory G R O P Last Name First Name Middle Initial Name of Facility Type Last Name First Name Middle Initial Name of Facility Type 5 Are you or anyone in the household who is sixteen (16) or older in high school, college, vocational school or a job-training program? If yes, complete the boxes below about each person. Last Name First Name Middle Initial School/Training Program Address Yes No S C H L Check One Full Time Half Time Less than Half Time Date of Completion Type Status Ver Count RIW Count SNAP MA GPA Last Name First Name Middle Initial School/Training Program Address Check One 6 Parent s Last Name Full Time Half Time Less than Half Time Date of Completion Type Status Ver Count RIW Count SNAP Besides you or your spouse, is there anyone in the household who Yes has children under age twenty-two (22) who also lives in the No household? If yes, complete the boxes below about each person. First Name Middle Initial Child s Last Name First Name Middle Initial Child s Last Name First Name MA P A R E Middle Initial GPA 7 Is there anyone who lives with you who purchases and prepares food separately? If yes, list the people who do not eat with you. Yes No E A T S Last Name First Name Middle Initial Last Name First Name Middle Initial Last Name First Name Middle Initial

12 Page 8 8 Are you or anyone in the household pregnant? Yes No If yes, complete the boxes below about the pregnant person. P R E G Last Name First Name Middle Initial Date Baby is Due Last Name First Name Middle Initial Date Baby is Due / _/ / / 9 Are you, your spouse, or anyone in the household mentally or physically ill, incapacitated, disabled or blind? If yes, complete the boxes below about each person. Last Name First Name Middle Initial Medical problem (describe) Yes No D I S A Caused by an accident? Yes Is this person active with the Office of Rehabilitation Services or Services for the Blind? Has this person applied for SSI or Social Security Benefits (RSDI)? If this person is a parent who is not working, does this person s disability make him/her unable to care for the child(ren)? Yes Yes Yes Last Name First Name Middle Initial Medical problem (describe) Factor Ver Review Blind Caused by an accident? Yes Is this person active with the Office of Rehabilitation Services or Services for the Blind? Has this person applied for SSI or Social Security Benefits (RSDI)? If this person is a parent who is not working, does this person s disability make him/her unable to care for the child(ren)? 10 Yes Yes Yes Are there children in the household whose parents are deceased? If yes, complete the boxes below about each person. Name of Deceased Parent: Last Name First Name Middle Initial Social Security Number / / Gender Male Female Factor Ver Date of Birth / / Yes No Review Blind D E C P Date of Death / / Ver List the children of this deceased parent in the spaces below. Last Name First Name Middle Initial P Last Name First Name Middle Initial P Last Name First Name Middle Initial P Last Name First Name Middle Initial P Last Name First Name Middle Initial P Last Name First Name Middle Initial P

13 11 Are there child(ren) in the household who do not have both parents (natural or adoptive) living with them? Page 9 State law assumes a child born during the time a couple is married or within 10 months of a final decree of divorce to be their child. List as the non-custodial parent, the present or former spouse of children born during that time. If divorce decree or court order excludes your spouse or former spouse as father of any of the child(ren) listed in the application, you need to list the biological parent of the child(ren) and provide copies of the decree or order with this application. If yes, complete the boxes below about each non-custodial parent and the children in this household of each non-custodial parent. A B S P Yes No Non-custodial Parent s Last Name First Name Middle Initial Sex M F Non-custodial Parent s Address Non-custodial Parent s SSN / / Non-custodial Parent s Telephone Number Parent s Birth Date / / Employer Name Employer Address Is this parent disabled and/or a veteran? Yes Were the parents of the child(ren) married to each other? Yes If yes, date married / / Child(ren) of the parent living in this household. Are the parents of the child(ren) currently married to each other? Yes If no, date divorced / / State of Birth Child s Last Name First Middle Initial 1. Yes 2. Yes 3. Yes 4. Yes Non-custodial Parent s Marital Status Never Married Divorced Widowed Married Separated Unknown Is child support, health coverage or paternity court ordered? (If yes, list date.) Support Date Health Cov Date Paternity Date Support Date Health Cov Date Paternity Date Support Date Health Cov Date Paternity Date Support Date Health Cov Date Paternity Date We ask information about the non-custodial parent so that we can seek child support from him/her. If you fear that you or your child will be harmed by the non-custodial parent if you help us in this process, you may be excused from cooperating. We will refer you to a Domestic Violence Advocate who can discuss this with you and help with safety planning. Check this box if you fear harm to either you or your child if you help us collect child support: Non-custodial Parent s Last Name First Name Middle Initial Sex M F Non-custodial Parent s Address Non-custodial Parent s SSN / / Non-custodial Parent s Telephone Number Parent s Birth Date / / Employer Name Employer Address Is this parent disabled and/or a veteran? Yes Were the parents of the child(ren) married to each other? Yes If yes, date married / / Child(ren) of the parent living in this household. Are the parents of the child(ren) currently married to each other? Yes If no, date divorced / / State of Birth Child s Last Name First Middle Initial 1. Yes 2. Yes 3. Yes 4. Yes Non-custodial Parent s Marital Status Never Married Divorced Widowed Married Separated Unknown Is child support, health coverage or paternity court ordered? (If yes, list date.) Support Date Health Cov Date Paternity Date Support Date Health Cov Date Paternity Date Support Date Health Cov Date Paternity Date Support Date Health Cov Date Paternity Date We ask information about the non-custodial parent so that we can seek child support from him/her. If you fear that you or your child will be harmed by the non-custodial parent if you help us in this process, you may be excused from cooperating. We will refer you to a Domestic Violence Advocate who can discuss this with you and help with safety planning. Check this box if you fear harm to either you or your child if you help us collect child support:

14 Question 11 (continued) Non-custodial Parent s Last Name First Name Middle Initial Sex M F Non-custodial Parent s Address Non-custodial Parent s SSN / / Non-custodial Parent s Telephone Number Page 10 Parent s Birth Date / / Employer Name Employer Address Is this parent disabled and/or a veteran? Yes Were the parents of the child(ren) married to each other? Yes If yes, date married / / Are the parents of the child(ren) currently married to each other? Yes If no, date divorced / / Child(ren) of the parent living in this household. State of Birth Child s Last Name First Middle Initial 1. Yes 2. Yes 3. Yes 4. Yes 5. Yes Non-custodial Parent s Marital Status Never Married Divorced Widowed Married Separated Unknown Is child support, health coverage or paternity court ordered? (If yes, list date.) Support Date Health Cov Date Paternity Date Support Date Health Cov Date Paternity Date Support Date Health Cov Date Paternity Date Support Date Health Cov Date Paternity Date Support Date Health Cov Date Paternity Date We ask information about the non-custodial parent so that we can seek child support from him/her. If you fear that you or your child will be harmed by the non-custodial parent if you help us in this process, you may be excused from cooperating. We will refer you to a Domestic Violence Advocate who can discuss this with you and help with safety planning. Check this box if you fear harm to either you or your child if you help us collect child support: Non-custodial Parent s Last Name First Name Middle Initial Sex M F Non-custodial Parent s Address Non-Custodial Parent s SSN / / Non-custodial Parent s Telephone Number Parent s Birth Date / / Employer Name Employer Address Is this parent disabled and/or a veteran? Yes Were the parents of the child(ren) married to each other? Yes If yes, date married / / Child(ren) of the parent living in this household. Are the parents of the child(ren) currently married to each other? Yes If no, date divorced / / State of Birth Child s Last Name First Middle Initial 1. Yes 2. Yes 3. Yes 4. Yes 5. Yes Non-custodial Parent s Marital Status Never Married Divorced Widowed Married Separated Unknown Is child support, health coverage or paternity court ordered? (If yes, list date.) Support Date Health Cov Date Paternity Date Support Date Health Cov Date Paternity Date Support Date Health Cov Date Paternity Date Support Date Health Cov Date Paternity Date Support Date Health Cov Date Paternity Date We ask information about the non-custodial parent so that we can seek child support from him/her. If you fear that you or your child will be harmed by the non-custodial parent if you help us in this process, you may be excused from cooperating. We will refer you to a Domestic Violence Advocate who can discuss this with you and help with safety planning. Check this box if you fear harm to either you or your child if you help us collect child support:

15 12 Are you or any other parent in the household unemployed or working only part time? (please check one) Unemployed Part-Time Page 11 YES No Last Name First Name Middle Did this person receive Dates Received: UC Ver Initial unemployment compensation Yes in the last 12 months? From to Did this person refuse a job or training program offer in the last 30 days? Yes Allow Has this person registered with the Department of Labor and Training (D.L.T.)? Yes Ver List the hours and weeks worked in the past 30 days below. List all the jobs held in the past five (5) years. Work Week Date No. of days Worked Hours Worked Employer s Name Employer s Address Dates of Employment Amount Earned Week one (1) From To Week two (2) From To Week three (3) From To Week four (4) From To Week five (5) From To Last Name First Name Middle Initial Did this person receive Dates Received: UC unemployment compensation Yes in the last 12 months? From to Did this person refuse a job or training program offer in the last 30 days? Yes Allow Has this person registered with the Department of Labor and Training (D.L.T.)? Yes Ver List the hours and weeks worked in the past 30 days below. Work Week Date No. of days Hours Worked Worked Week one (1) Week two (2) Week three (3) Week four (4) Week five (5) List all the jobs held in the past five(5) years. Employer s Name Employer s Address Dates of Employment From To From To From To From To From To Ver Amount Earned 13 Did you or anyone in the household leave a job in the last sixty (60) days or is anyone on strike? Yes No If yes, complete the boxes below. Q U I T/STRK Last Name First Name Middle Initial Employer s Name Reason for leaving job Employer s Address Date left job/date Strike Began / /

16 Questions b ask about resources-- money and things you own. Page 12 IF YOU ARE APPLYING FOR SNAP ONLY, DO NOT FILL OUT QUESTIONS 14-19b UNLESS OTHERWISE INSTRUCTED BY YOUR DHS WORKER DURING YOUR INTERVIEW. PLEASE CONTINUE TO QUESTION Do you, your spouse, or anyone in the household have any cash? Yes No If yes, complete the boxes below about each person with cash. C A S H Last Name First Name Middle Initial Amount Last Name First Name Middle Initial Amount 15 Do you, your spouse, or anyone in the household have his/her name on any accounts such as the type listed below? Yes No EXAMPLES: Checking account Credit union account Savings certificate IRA Mutual Funds Savings account Money market account Certificate of deposit Annuity Trust Burial Set Aside If yes, complete the boxes below for each account. B A N K Last Name First Name Middle Initial Type of account Account number Amount Co-owner name Address Financial Institution Address Last Name First Name Middle Initial Type of account Account number Amount Co-owner name Address Financial Institution Address Last Name First Name Middle Initial Type of account Account number Amount Co-owner name Address Financial Institution Address Last Name First Name Middle Initial Type of account Account number Amount Co-owner name Address Financial Institution Address Last Name First Name Middle Initial Type of account Account number Amount Co-owner name Address Financial Institution Address

17 15a Did you, your spouse, or anyone in the household receive a Social Security, Retirement, Survivors and Disability (RSDI) lump sum in the past 6 months? If yes, complete box below. Last Name First Name Middle Initial Amount received 16 Do you, your spouse, or anyone in the household own, and/or have registered in his/her name any vehicle such as the types listed below? EXAMPLES: Car Boat Truck Motorcycle Camper Snowmobile Recreational Vehicle Page 13 Yes No Date received / / Yes No If yes, complete the boxes below for each vehicle. Owner s Last Name First Name Middle Initial Vehicle Make Model Year Blue book value What is the vehicle used for? (ex: work, everyday use, transportation for disabled household member) Amount owed Vehicle ID Number Registration Number C A R S Insurance Company Owner s Last Name First Name Middle Initial Vehicle Make Model Year Blue book value What is the vehicle used for? (ex: work, everyday use, transportation for disabled household member) Insurance Company Amount owed Vehicle ID Number Registration Number Owner s Last Name First Name Middle Initial Vehicle Make Model Year Blue book value What is the vehicle used for? (ex: work, everyday use, transportation for disabled household member) Amount owed Vehicle ID Number Registration Number Insurance Company

18 17 Do you, your spouse, or anyone in the household own any items of value? (Include any items of value not listed in questions 14, 15 or 16) EXAMPLES: Stocks Personal Property (antiques, collections, jewelry, etc.) Burial Contract Bonds Life Insurance Reverse Mortgages Long-term Care Insurance If yes, complete the boxes below. R E S O STOCKS, BONDS, OTHER Last Name First Name Middle Initial Type of Resource Co-owner s Last Name First Name Middle Initial Co-owner s Address Page 14 Yes No Last Name First Name Middle Initial Type of Resource Co-owner s Last Name First Name Middle Initial Co-owner s Address Last Name First Name Middle Initial Type of Resource Co-owner s Last Name First Name Middle Initial Co-owner s Address LIFE INSURANCE/LONG-TERM CARE INSURANCE Last Name First Name Middle Initial Company Name Policy Number Type Owned By Face Value Cash Value Loan Amount Last Name First Name Middle Initial Company Name Policy Number Type Owned By Face Value Cash Value Loan Amount Last Name First Name Middle Initial Company Name Policy Number Type Owned By Face Value Cash Value Loan Amount BURIAL CONTRACT Last Name First Name Initial Value Irrevocable Effective Date Funeral Home Funeral Home Address / / Last Name First Name Initial Value Irrevocable Effective Date / / Funeral Home Funeral Home Address

19 18 Page 15 Do you, your spouse, or anyone in the household own any interest in any property such as land, buildings, life estate, timeshare, etc? (Unless you are applying for LTSS, do not report the home in which you live) Yes No If yes, complete the boxes below about each person. Owner s Last Name First Name Middle Initial Type of property (describe) Cash Value Amount Owed How is the property owned? Address of Property Solely Jointly Life Estate Other Is this property your home? Yes No The home of your spouse? Yes No Your dependents? Yes No 19 Have you, your spouse, or anyone in the household given away, sold, deeded, or transferred to anyone or any entity, any items of value in the past sixty (60) months? Yes No If you are applying for SNAP benefits only and asked to answer this question, report the items of value that were transferred within the last three (3) months. If yes, complete the boxes below. Last Name First Name Middle Initial Resource Transferred P R O P T R A N Amount Transferred Date Transferred / / What did you receive in return? Last Name First Name Middle Initial Resource Transferred Amount Transferred Date Transferred / / What did you receive in return? Last Name First Name Middle Initial Resource Transferred Amount Transferred Date Transferred / / What did you receive in return? 19a Are you named as a beneficiary (primary, secondary, etc.) on any trust? If yes, you must provide copies of the trust even if you are not currently receiving any payments from the trust. Principal amount and date established Date /_ / 19b Amount of payments to you Frequency of payments to you Have you, your spouse, or anyone acting on your behalf (including a court) established a trust or put any money or other resource into a trust within the last sixty (60) months? No Yes No Has any property come out of a trust within the last sixty (60) months? Yes No If yes, you must provide copies of the trust and describe all such transactions into or out of the trust. Established by Date established / / Amount

20 20 Do you or anyone in the household have or expect income from a job this month? Note: If you are self-employed, you will be asked to provide that information in question 25. EXAMPLES Salaries/Wages Commissions National Guard Army Reserve Work Study Job Training Sheltered Workshop US Military If yes, complete the boxes below about each person. Last Name First Name Middle Initial Employer Name and Address Page 16 Yes No J I N C Date Job Began/Will Begin Type of Work Day of Week Paid How Often Paid: Weekly Every two weeks Twice a month Monthly Other List the gross amount paid on each pay day this month. Pay Day Date Paid Pay period end date Hours worked per pay Gross wages before Tips/Commissions period taxes 1st / / / / 2nd / / / / 3rd / / / / 4th / / / / Did you receive earned income tax credit in your paycheck? Yes No Is this job part of a work study program? Yes No Is this an On the Job training program? Yes No Will this income be received in the following month? Yes No List the number of hours you expect to be paid for next month: Number of Hours: Expected Gross Earnings: Tips/Commissions: Work/School/Training Schedule (Child Care only) Day Start Time End Time Monday Tuesday Wednesday Thursday Friday Saturday Sunday If your schedule varies, please explain how (you may send additional documentation to verify).

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